This enables them to build links with the GP and their practice staff, district nurses and other community-based professionals working in the locality. This means that each patient has a named specialist palliative care nurse whom he/she gets to know well, but back-up is available from the other nurses in that ‘buddy team’.
If possible, home visiting is preceded by an outpatient clinic assessment to determine an appropriate care plan with the patient. After that, home visiting by a Sobell specialist nurse enables the nurse to continue assessment of the patient – physically, emotionally and socially – and to try to improve problems or difficulties through medications, therapies, counselling, practical advice and information. The frequency of the visits is dictated by the patient’s needs and preferences, as well as the service capacity.
The specialist nurse will continue to visit the patient at home as long as the individual needs this level of support and is happy for it to occur. From time to time, outpatient appointments with a senior doctor, or home visits by a doctor or occupational therapist, may be arranged if this might be helpful.
If home visiting is no longer necessary, the specialist nurse will suggest transferring to the telephone support service or discharging from Sobell House altogether. The patient and his/her GP will be consulted in this decision.